Application and Manuscript Submission Form

APPLICATION AND MANUSCRIPT SUBMISSION FORM

THE UCI UNDERGRADUATE RESEARCH JOURNAL

A multi-disciplinary publication of exceptional research papers completed by UCI undergraduates

If you have any questions, please contact the UROP Office in Student Services II, Suite 2300

Phone: (949) 824-4189  E-mail:  Website:

DEADLINE TO SUBMIT APPLICATION AND MANUSCRIPT: MONDAY, JUNE 30, 2003

Please type or print clearly in blue or black ink. Make copies as needed. Incomplete applications will not be considered.

PROJECT INFORMATION

TYPE OF PROJECT: Independent Research/Creative Project Group Research/Creative Project

Does this project involve the student's use of human subjects or data/specimens from living humans? YES NO

If yes, please provide the approved IRB protocol number: ______(Note: student's name must be listed on protocol)

Does this project involve the student’s use of live vertebrate animals? YES NO

If yes, please provide the approved IACUC protocol number: ______(Note: student’s name must be listed on protocol)

Area of Research: ______

Manuscript Title: ______

RESEARCHER(S) INFORMATION (Please attach information for additional group members, if applicable.)

NAME (last, first, middle): ______STUDENT ID: ______

MAJOR(s): ______E-MAIL: ______

LOCAL ADDRESS PERMANENT ADDRESS

Street: ______Street: ______

City: ______State: ______Zip: ______City: ______State: ______Zip: ______

Phone: ( ) ______Phone: ( )______

ON- AND OFF-CAMPUS FACULTY MENTOR(S) INFORMATION
(Please attach information for additional faculty mentors, if applicable.)

NAME (last, first, middle): ______DEPARTMENT: ______

UCI ADDRESS: ______ZOT CODE:______PHONE: ______E-MAIL: ______

OFF-CAMPUS ADDRESS (only for non-UCI mentors):

Street: ______City: ______State: ____ Zip: ______

FACULTY MENTOR SIGNATURE* (required): ______DATE: ______

My signature above affirms that I have reviewed and approved the attached manuscript for submission to publish in The UCI Undergraduate Research Journal, and I hereby indicate my support for the publication and reproduction of the manuscript by UROP.

*In the event of publication, you will be contacted for further information regarding this project.

LIABILITY RELEASE CERTIFICATION

My signature hereby certifies that all references, citations, quotations, images, tables, illustrations, charts, diagrams, and graphs are accurate and have been properly credited. My signature also certifies that, where applicable, I (we) have obtained written permission from the copyright owner to publish all references, citations, quotations, images, tables, illustrations, charts, diagrams, and graphs or parts thereof contained in their original work in The UCI Undergraduate Research Journal. My signature further agrees to indemnify and hold harmless The UCI Undergraduate Research Journal or UROP from any and all liability resulting from a breach of this certification.

SIGNATURE

OF AUTHOR(S): ______DATE: ______